Diacetylmorphine is an semi synthetic drug synthesized from morphine is a derivative of the opium poppy also commonly known as the illicit drug Heroin or street name 'Smack'. Heroin an opioid comes in the form of a white matte powder and over 90% of Heroin is said to be produced in Afghanistan (Sneader 2005). Heroin is used as a pain-killer and recreational drug that has an extremely high potential for abuse which we see in present day amongst users. Heroin in most countries is illegal to possess and produce without license however some countries such as the UK prescribe Heroin under the name diamorphine as an analgesic. Heroin in its history has been used for medical purposes such as a substitute for morphine as a cough suppressant. There are an estimated 50 million regular users of Heroin, Cocaine and synthetic drugs worldwide (Drug Trade 2000), users of heroin alone globally amount to estimates of 15.16 million to 21.13 million people aged 15-64 (llegal drugs: Canada's growing international market 2009). For many illicit drug users around the world Heroin use is a problem, this paper will look at Heroin overall as an illicit drug, the reasons behind why it's use is prevalent, it's history, the extent of the use in Australia, harm minimisation, current programs and barriers as well as future trends and its' implications for health promotion.
DESCRIPTION OF THE DRUG ITS HISTORY OF USE
Heroin is an 'opioid', and is a depressant that slows down the activity in the central nervous system and the messages going to and from the brain and body. It comes in the form of usually white powder but can be brown or rock form. Users usually administer Heroin injected into the vein, it can be smoked, snorted or added to cigarettes. Heroin gives the user a sense of intense pleasure and a strong feeling of wellbeing other symptoms also include pain relief, slowed breathing, decreased blood pressure, dry mouth, drowsiness, nausea and vomiting. Long term effects of heroin include dependence, depression and other withdrawal symptoms.
It is thought that the Arab traders during the 7th and 8th century AD brought opium to China where it was used in their 'opium dens' for many years for recreational use (Opium Through Out History n.d). Heroin became known in the late 1874, when a English chemist working at St.Mary's Hospital London had been experimenting combining morphine with other acids to finally find a more potent form of morphine which was named diacetylmorphine (Wright 2003). There were no further developments on diacetylmorphine as Wright was unsure of its' potential, only the results found by himself after he had tested it on animals (Wright, 2003). Diacetylmorphine only became popular when 24 years later in 1897 Chemist Felix Hoffmann at Bayer Pharmaceuticals Berlin, Germany independently synthesised diacetylmorphine and Bayer immediately recognised its potential and began heavily marketing it giving it the name 'Heroin'. Bayer suggested it was a treatment for coughs and respiratory conditions as well as a less addictive substitute for morphine. Little did they know the full effects of Heroin until a few years on (Tribby 2008; Sneader 2005). Bayer went on to export Heroin around the world to 23 countries marketing it heavily only till in the early 1900's doctors and pharmacists began noticing that patients were consuming large amounts of Heroin containing cough remedies. In 1913 Bayer is forced to cease producing Heroin (Sneader 2005).
By 1925 there were an estimated 200,00 heroin addicts in the Country. The use and addiction of Heroin continued through to the war in Vietnam (Robins et al, 1975). The use of Heroin amongst soldiers during the war accounted for 10-15% of soldiers and the US involvement in the Vietnam war was blamed to be the reason behind the surge in illegal Heroin being smuggled into the states (Robins et al, 1975).
EXTENT OF USE IN AUSTRALIA
Illicit heroin use was first noted in Sydney and Melbourne in the late 1960's (Manderson,2003) where Heroin use in Australia was reportedly introduced by American soldiers on leave from Vietnam where heroin was freely available and commonly smoked (Manderson, 2003; Robins et al, 1975).
Historical information suggests that illicit Heroin use by young adults largely developed in the late 1960's in Australia, with a major period of use during 1982 -1985 (Manderson,2003). The first major epidemic of illicit heroin use in Australia occurred in the early 1970s which prompted the establishment of methadone maintenance treatment programs to help combat the addiction (Mattick and Hall, 2003). 1985 saw the substantial expansion of methadone maintenance treatment for opioid dependence (Mattick and Hall, 2003) and by 1987 concern about HIV transmission via shared injection equipment led to the introduction of needle and syringe programs to help contain the spread of HIV/Aids (Feacham, 1995).
The Australian Bureau of Crime Intelligences' Australian Illicit Drug Report (AIDR) (2007) believes that Opium production in South West Asia increased over the last decade increasing the amount of Opium being trafficked into Australia. Information gathered by Interpol and presented to the Crime commission provides evidence that South-West Asia is a main source region for Heroin seized in Australia (Interpol 2007).
According to the 2007 National Drug strategy Household Survey (NDSHS), 0.2 per cent of the population used heroin in the previous 12 months which accounted for 347,900 of the population which is a relatively small amount in Australia (AIHW, 2008). This is consistent with the levels reported in 2001 and 2004, and lower than the 0.8 per cent reported in 1998.. In the 2007 NDSHS report it suggested that males were more susceptible to drug intake than woman with a comparison rate of 226,700 males versus 121,500 females. It went on to suggest that the average age at which Australians first used Heroin was at 21 years old and that 60% of users used as frequent as weekly however 14.3% of users used Heroin of Methadone only once or twice a week. This figure suggests that Heroin use is addictive and there is a dependency on its use amongst young adults that use it. Many of the users preferred to inject Heroin which accounted for 89.0% and 57.7% smoked it proving that many users found the effects of injecting Heroin stronger than smoking (AIHW, 2008).
This figure demonstrates a cause for concern as many deaths related to Heroin use are due to overdose and the lethal effects of not being able to control the effects of Heroin entering the bloodstream immediately via injection. A high number of users usually use Heroin at home or a friends place, 67.7% percent at home and 51.1% at a friends place suggesting that many a time Heroin users are alone which often results in an overdose sometimes it proving to be fatal (AIHW, 2008). There have been many cases of deaths due to overdose where individuals have taken Heroin alone and not with another person who was able to 'spot' for them. Up to 66.4% users of Heroin use Heroin concurrent with marijuana/cannabis or other form of drug, which adds to it's lethal affects.
In Australia the use of Heroin is relatively low, due to border security measures such as customs and the AFP constantly tracking sources of Heroin from various parts of Asia and around the world. However only certain drug types are examined and not every seizure of drugs at the Australian border is analysed (AFP, 2006) thus sometimes Heroin being able to slip through our borders on to the streets.
CURRENT HARM MINIMISATION PROGRAMS IN AUSTRALIA & INTERNATIONALLY
Harm minimisation considers the actual harms associated with the use of a particular drug (rather than just the drug use itself), and how these harms can be minimised or reduced. It recognises that drugs are, and will continue to be, a part of our society. Three main strategies of harm minimisation is supply reduction, demand reduction and harm reduction (NDS, 2010). There have been several campaigns implemented by the Australian Government and Private Groups to help minimise the effects of drugs in the Australian Community.
The National Illicit Drugs Campaign (NIDC)
The National Drugs Campaign part of the National Drugs Strategy was implemented in 2001, the program helps young peoples and their parents understand the harmful affects and consequences of drug use. The campaign uses a combination of primary prevention and targeted intervention communications through advertising, public relations and promotions, resource development and online communication activities to reach its target group of people. The National Illicit Drugs campaign that is rolled out in different phases according to market trends of current drugs in use has been affective and notable many of their campaigns has targeted the correct audiences as there was a decline in the number of users of illicit drugs since their last campaign especially in youth aged 14-19 (NDSHS, 2008)
Where's your head at? Mass Media Demand Reduction Campaign
The Where's your head at campaign was aimed at encouraging people not to use, delay use, or to use less of a drug through information and education strategies, treatment programs and regulatory controls. It was focused on youth and young adults and displayed negative images via mass media, television, radio, posters, presentations and workshops to display the negative effects of Heroin and other drugs (NDS, 2010). It was evident that by the possible combination of elements of the "Where's your head at?" Campaign in conjunction with strategies from the National Illicit Drugs Campaign there was a reduction in the use of illicit drugs
Supervised Injecting Rooms Harm Reduction Program
In Germany and in Sydney supervised safe injecting rooms have been established to give Heroin users a safe way to inject while under supervision which otherwise might occur in less safe circumstances such as public places or alone (Dolan and Wodak, nd). Germany initially started with the concept which has now spread around Europe and to Australia. However the Medically Supervised Safe Injecting House (MSIC) has proven itself useful and cost effective in helping people and their fight against drugs (MSIC, 2010). The MSIC has proven to reduce the number of deaths and injuries relating to drug use and reduce the transmission of blood borne viruses by providing new needles, but the centre offers a way of keeping track of the number of users while providing assistance and minimising harm (MSIC, 2010).
BARRIERS TO PREVENTION/HARM MINIMISATION APPROACHES
An important aspect of harm minimisation is its focus on public health which has improved co-operation between health, social, justice and law enforcement sectors and services in Australia. The Public health approach to harm minimisation in Heroin demonstrates a key few areas in which further harm can be minimised.
Increasing Access and Utilisation of Methadone Maintenance and other Treatment
Individuals who are enrolled in a Methadone maintenance program are at lower risk of having an overdose (NDSHS , 2008). According to Schwartz et al (2009) amongst a 10,000 group of patients receiving methadone maintenance they reported that the mortality rate among methadone maintenance patients (7.6 per 1,000) was similar to that in the general population (5.6 per 1,000). It was significantly lower than the mortality rate among those who left the methadone maintenance program (28.2 per 1,000) and among opioid users not in treatment (82.5 per 1,000).
Educating Injecting Drug Users about the Dangers of Polydrug Use.
Williamson et al (2007) suggest that the concurrent use of other central nervous system depressant drugs with heroin heighten the risk of fatal opioid. It is also been a recurrent fact amongst much literature that there is a heightened risk of overdose. It is therefore important that heroin users are informed about the risks of combining heroin with alcohol and other depressant drugs.
Encouraging Injecting Drug Users not to Inject Alone.
Heroin users as noted in the NDSHS (2008) often take Heroin alone at home or at a friend's place. Often Heroin users are alone which can prove fatal if there's an overdose. Part of the National drug strategys' campaign is to encourage users to do with a friend around if they choose not to use a safe injecting house. Recent proposals for increasing the number of safe injecting rooms into areas where there are a number of street injections would be worth serious consideration as a way of reducing overdose deaths caused by these risky practices.
Establishing Safe Injecting Rooms
Many communities and political groups find themselves opposed to safe injecting rooms, because many people are often afraid of having a safe injecting centre in their 'backyard' fears that it might attract violent and destructive behaviour in the area. Safe injecting rooms are places in which injecting drug users are able to inject drugs in a clean environment with sterile equipment under the supervision of trained staff that can assist in the case of a overdose. Safe injecting houses are designed to reduce the risks associated with injecting drugs in public to long term users, including deaths from overdoses, and the transmission of HIV. Safe injecting houses also provide a way for injecting users to get help and start on methadone programs (MSIC, 2010)
There is evidence to suggest that supervised injecting rooms hold benefits for both users and the
community. Injecting rooms were opened in 1991 in Frankfurt, Germany, as part of a program of harm
minimisation that included needle exchange and methadone maintenance programs. In the following
years, the number of lethal overdoses in Frankfurt declined by 80%, compared to a 20% reduction in
Germany as a whole, suggesting that the program, of which injecting rooms had formed a part, was
effective in significantly reducing overdose deaths (Joint Select Committee into Safe Injecting Rooms,
FUTURE TRENDS IN USE AND IMPLICATIONS FOR HEALTH PROMOTION
Heroin use in Australia is currently a topic of great political and public concern in Australia and will be for times to come as long as there is an increase in the amount of Heroin coming in to the country. Analyses of data in the AIDR (2008) suggest that Police and Customs have reported an increase in the amount and availability on the streets even after large amounts being confiscated by them. This suggests that traffickers are finding other means of bringing it into the country. However it has been found in the AIDR (2008) that there has been a decline in the average age of injecting drug users which seems promising for the future suggesting that many users are moving of the use of Heroin or finding other methods than injecting. For the future persistence with campaigns and education and an all rounded public health approach in association with government bodies, health, social, justice and law enforcement sectors and services should help see the numbers diminish even more.
The use of Heroin has declined over the years due to harm minimisation programs and education campaigns targeting users; educating them in the harms and consequences of using Heroin. Government policies and campaigns and further harm minimisation enforcements through customs and the Australian Federal Police has helped reduce the amount of Heroin that is accessible on the streets of Australia. The Governments' support to make more safe injecting rooms possible can further assist in reducing the number of mortalities related to injecting drug use as well as help regular users with methadone programs. The main area of concern is not only reducing the number of users but also reducing the number of mortalities related to Heroin use, further increased education and campaigns targeting areas and specific age groups will further reduce the casualty rate however possibly not completely eradicate the problem.